Guideline on Medication and the Risk of Falling

Purpose  This guideline provides advice and information relating to medication and the risk of falls  The guideline complements and may be used as an aide when completing the Trusts patients Falls Assessment

Scope This guideline is applicable to all Dorset HealthCare staff that may have a responsibility for assessing a patient’s medication in relation to their risk of falling.

Responsibility  This guideline is not a comprehensive list of all drugs but is intended to raise awareness of the types of drugs which can cause falls.  Please refer to a member of the Pharmacy team for further information and clarification if required.

Related Documents DHC Patients Falls Assessment

1. Clinical objectives 1.1 All patients should have their drug burden reviewed with respect to likelihood to cause falls. 1.2 The drug history should establish the reason the drug was given, when it was started, whether it is effective and what its side effects have been. 1.3 An attempt should be made to reduce the number and dosage of medications and ensure they are appropriate and not causing undue side effects

2. Medicines and risk of falling 2.1 Falls can be caused by almost any medicine that acts on the brain or circulation 2.2 Taking a drug which acts on the brain can double the risk of a fall. 2.3 Taking 2 or more drugs that can affect the circulation or brain can double the risk of a fall. 2.4 Falls may be a result of recent medication change but are usually caused by medicines that have been given for some time. 2.5 Polypharmacy is an independent risk factor for falls. Patients on four or more medicines of any type are at greater risk of a fall

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 1 of 6

2.6 The mechanism leading to a fall is usually one or a combination of: o Sedation; slowing of reaction time and impaired balance o Hypotension; including orthostatic hypotension, vasovagal syndrome, vasodepressor carotid sinus hypersensitivity o Cardiac changes; bradycardia, tachycardia, periods of asystole

3. Intrinsic risk factors 3.1 The risk of having a fall or recurrent falls increases with the number of associated intrinsic risk factors listed below:

o Previous fall o Visual impairment o Poor mobility / gait o Alcohol > 1unit/day o Balance disorders o Orthostatic hypotension o Cognitive impairment o Hearing impairment o Polypharmacy o Psychotropic drugs use

4. Risk Stratification 4.1 Appendix A provides a classification of medicines into groups based on the likelihood of causing a fall based on evidence and pharmacological side effect profiles.

5. References Alsop K, MacMahon M. Withdrawing cardiovascular medications at a syncope clinic. Postgrad MJ 2001;77:403-5. Darowski A, Chambers SCF and Chambers DJ (2009). Antidepressants and falls. Drugs and Aging 26 (5) 381-394 Darowski A, Dwight J, Reynolds J (2011a) Medicines and Falls in Hospital. John Radcliff Hospital) Darowski A and Whiting R. (2011b) Cardiovascular drugs and falls. Reviews in Clinical Gerontology, 21 (2) 170-179 DCCG (2013) Caring for Care Homes – Drugs and Falls Guidance Sheet 5. N.E.W Devon Clinical Commissioning Group, South Devon and Torbay Clinical Commissioning Group. [Accessed 16-Jan-15] Leipzig RM, Cumming RG, Tinetti ME. (1999) Drugs and Falls in Older People: A systemic Review and Meta-analysis: I. Psychotropic Drugs. J AM Geriatric Soc. Jan;47(1):30-9. Van der Velde N, van den Meiracker AH, Pols HA, Stricker BH, van der Cammen TJ. (2007) Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc 55:734–739

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 2 of 6

Appendix A: Medicines and the Risk of Falling (Adapted from Darowski A, Dwight J, Reynolds J (2011) Medicines and Falls in Hospital. John Radcliff Hospital) This risk classification is based on published evidence of medicines implicated in falls. This list is not fully inclusive but highlights groups of drugs where particular care is required. Please refer to a member of the Pharmacy team if further information is required

High Risk – medicines that can commonly cause falls on their own or in combination

Medicine Class Examples Effects that may lead to a fall Benzodiazepines Temazepam, nitrazepam, Drowsiness, slow reaction times, diazepam. Lormetazepam. impaired balance. Particular Chlordiazepoxide, flurazepam. caution required in patients whom Lorazepam, oxazepam, have been taking for some time. clonazepam

Z-drugs Zopiclone, zolpidem Drowsiness, slow reaction times, impaired balance.

Tricyclic Amitriptyline, dosulepin, All have some  blocking ability antidepressants imipramine, doxepin, and can cause orthostatic clomipramine, lofepramine, hypotension. All have nortriptyline, trimipramine antihistamine properties and can cause drowsiness, impaired Other Mirtazapine, trazadone, balance and slow reaction times. antidepressants mianserin Can double the rate of falling. Nortriptyline, imipramine and lofepramine are associated as being less sedative compared to others in the class.

SNRI Venlafaxine, duloxetine Can cause orthostatic hypotension antidepressants through noradrenaline reuptake blockade.

Monamine oxidase Phenelzine, isocarboxazid, Cause severe orthostatic A inhibitors tranylcypromine hypotension

Drugs for psychosis Chlorpromazine, haloperidol All have some  blocking ability and agitation fluphenazine, risperidone, and can cause orthostatic quetiapine, olanzapine hypotension. Sedation, slow reflexes, loss of balance.

Opiate analgesics All opiates and related Sedate, slow reactions, impair analgesia – e.g. codeine, balance, cause delirium morphine tramadol

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 3 of 6

High Risk continued….

Medicine Class Examples Effects that may lead to a fall

Antiepileptic’s Phenytoin Phenytoin may cause permanent cerebellar damage and unsteadiness in long term therapeutic dose. Toxicity due to excessive blood levels cause ataxia and unsteadiness. Carbamazepine Sedation, slow reaction times. Toxicity due to excessive blood Phenobarbitone levels cause ataxia and unsteadiness. Parkinsons Disease Ropinirole, pramipexole, May cause delirium and orthostatic Dopamine agonists bromocriptine, cabergoline, hypotension pergolide Monoamine oxidase Selegiline Causes orthostatic hypotension - B inhibitors

 receptor blockers Doxazosin, tamsulosin, Cause orthostatic hypotension prazosin

Centrally acting 2 Clonidine, moxonidine May cause severe orthostatic receptor agonists hypotension. Also sedating

Thiazide diuretics Bendroflumethazide, Causes orthostatic hypotension, chlortalidone, metolazone weakness due to low potassium. Hyponatraemia. Angiotensin Lisinopril, Ramipril, enalapril, Decrease in peripheral resistance Converting Enzyme captopril, perindopril and drop in blood pressure. These Inhibitors drugs rely almost entirely on the kidney for their elimination and can accumulate in dehydration and renal impairment. Fosinopril, trandolapril, Excreted by kidney and liver quinapril Beta Blockers Atenolol, sotalol (renally Initial decrease in cardiac output, excreted can accumulate in decrease in peripheral vascular renal impairment) resistance. Can cause bradycardia, hypotension, Bisoprolol, metoprolol, orthostatic hypotension and propranolol, carvedilol, timolol vasovagal syndrome eye drops Common cause of syncope due to Antianginals GTN sudden loss of BP Isosorbide mononitrate, Causes hypotension and nicorandil paroxysmal hypotension Long acting oral Glimepiride, glibenclamide, Long acting sulfonylureas have Hypoglycaemics chlorpropamide increased associated risk of causing hypoglycaemia.

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 4 of 6

Moderate risk: these medicines can cause falls especially in combination

Medicine Class Examples Effects that may lead to a fall

SSRI Sertraline, citalopram, Several population studies show antidepressants paroxetine, fluoxetine that SSRIs are consistently associated with an increased rate of falls and fractures, but there are no prospective trials. The mechanism of such an effect is unknown. They cause orthostatic hypotension and bradycardia rarely. They do not normally sedate but can disturb sleep.

Antiepileptics Sodium valproate, gabapentin, Some data on falls association pregabalin

Muscle relaxants Baclofen, dantrolene Sedative, reduce muscle tone

Loop diuretics Furosemide, bumetanide Dehydration causes hypotension. Low potassium and sodium

Angiotensin II Losartan, candesartan, May cause less orthostatic receptor Blockers valsartan, irbesartan, hypotension then ACE inhibitors. olmesartan, telmisartan, Excreted by kidney and liver eprosartan

Calcium channel (Dihydropyridines) Vasodilatation; may cause blockers that only hypotension and paroxysmal Amlodipine, felodipine, reduce blood hypotension nifedipine, lercanidipine, pressure lacidipine, nimodipine

Calcium channel (Phenylalkylamines) May cause hypotension or blockers which slow bradycardia Verapamil the heart and reduce blood (Benzothiazepines) pressure Diltiazem

Other Digoxin, amiodarone, Cause symptomatic bradycardia antidysrhythmics flecainide and syncope (NB patient’s condition may predispose them to falls)

Oral (Sulfonylureas) Hypoglycaemics Gliclazide, glipizide, Release insulin, may cause tolbutamide hypoglycaemia in periods of poor diabetic control e.g. illness (metglitinides) Nateglinide, repaglinide

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 5 of 6

Possible risk of falls: these medicines possibly cause falls, particularly in combination, published evidence of direct causal link is lacking, medical condition may mean that patient more likely to fall

Medicine Class Examples Effects that may lead to a fall

Antiepileptics Lamotrigine, levetiracetam, May cause falls, insufficient data topiramate, zonisamide available

Vestibular sedatives Prochlorperazine Dopamine antagonist – may cause movement disorder in long term. Also has  blocking ability (can cause orthostatic hypotension) and antihistamine properties causing sedation. NB being used to treat a condition associated with falling.

Cinnarizine, betahistine Antihistamines – sedating. NB being used to treat a condition associated with falling.

Sedating Chlorphenamine,hydroxyzine, Sedation likely to contribute to antihistamines for promethazine, trimeprazine falls; drugs have long halve life’s. allergies However lack of data on contribution to falls risk.

Anticholinergics Oxybutynin, tolterodine, Lack of data on falls risk, but acting on bladder duloxetine, solifenacin pharmacologically have CNS effects as well as effects on the autonomic nervous system

Dementia drugs Donepezil, rivastigmine, May cause symptomatic galantamine bradycardia and syncope. (Acetylcholinesterase inhibitors)

Proton pump Omeprazole, lansoprazole Rare reports of dizziness, inhibitors confusion, blurred vision and drowsiness

Written by A. Hocking (Lead Pharmacist) Review date: February 2020 Approved by: Medicines Management Group Date: 22 February 2018 Page 6 of 6